Comparative Analysis of Symptomatic and Asymptomatic Carotid Plaque With Bilateral Mild Carotid Stenosis (30%–50%)

HomeStrokeVol. 54, No. 7Comparative Analysis of Symptomatic and Asymptomatic Carotid Plaque With Bilateral Mild Carotid Stenosis (30%–50%) Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBComparative Analysis of Symptomatic and Asymptomatic Carotid Plaque With Bilateral Mild Carotid Stenosis (30%–50%) Atulabh Vajpeyee, Pushan Sharma, Piyush Kumar Anshu, Shivam Tiwari, Lokendra Bahadur Yadav, Kapil Vyas and Manisha Vajpeyee Atulabh VajpeyeeAtulabh Vajpeyee Correspondence to: Atulabh Vajpeyee, MD, DM (Neurology), FINS, Department of Neurosciences, Pacific Medical College and Hospital, Pacific Medical University, Udaipur, India, 313001. Email E-mail Address: [email protected] https://orcid.org/0000-0002-7942-4302 Department of Neurosciences, Pacific Medical College and Hospital, Pacific Medical University, Udaipur, Rajasthan, India (A.V., P.S., P.K.A., S.T., L.B.Y.). Department of Neurosciences, Pacific Medical College and Hospital, Pacific Medical University, Udaipur, Rajasthan, India (A.V., P.S., P.K.A., S.T., L.B.Y.). Search for more papers by this author , Pushan SharmaPushan Sharma https://orcid.org/0000-0002-4965-6655 Department of Neurosciences, Pacific Medical College and Hospital, Pacific Medical University, Udaipur, Rajasthan, India (A.V., P.S., P.K.A., S.T., L.B.Y.). Search for more papers by this author , Piyush Kumar AnshuPiyush Kumar Anshu https://orcid.org/0000-0003-1606-9208 Department of Neurosciences, Pacific Medical College and Hospital, Pacific Medical University, Udaipur, Rajasthan, India (A.V., P.S., P.K.A., S.T., L.B.Y.). Search for more papers by this author , Shivam TiwariShivam Tiwari https://orcid.org/0000-0001-9465-1215 Department of Neurosciences, Pacific Medical College and Hospital, Pacific Medical University, Udaipur, Rajasthan, India (A.V., P.S., P.K.A., S.T., L.B.Y.). Department of Neurosciences, Pacific Medical College and Hospital, Pacific Medical University, Udaipur, Rajasthan, India (A.V., P.S., P.K.A., S.T., L.B.Y.). Search for more papers by this author , Lokendra Bahadur YadavLokendra Bahadur Yadav https://orcid.org/0000-0002-5035-0573 Department of Neurosciences, Pacific Medical College and Hospital, Pacific Medical University, Udaipur, Rajasthan, India (A.V., P.S., P.K.A., S.T., L.B.Y.). Department of Neurosciences, Pacific Medical College and Hospital, Pacific Medical University, Udaipur, Rajasthan, India (A.V., P.S., P.K.A., S.T., L.B.Y.). Search for more papers by this author , Kapil VyasKapil Vyas Department of Radiology (K.V.), Pacific Medical College and Hospital, Pacific Medical University, Udaipur, Rajasthan, India. Search for more papers by this author and Manisha VajpeyeeManisha Vajpeyee https://orcid.org/0000-0001-5010-2863 Department of Reproductive Medicine and Research (M.V.), Pacific Medical College and Hospital, Pacific Medical University, Udaipur, Rajasthan, India. Search for more papers by this author Originally published2 Jun 2023https://doi.org/10.1161/STROKEAHA.123.042874Stroke. 2023;54:e294–e295Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: June 2, 2023: Ahead of Print Ischemic strokes are frequently caused by atherosclerotic plaque in the carotid arteries.1 Histologically vulnerable plaques with intraplaque hemorrhage, fibrous cap rupture, large lipid necrotic core, and mural thrombus.2 Almost half of the carotid plaque in stroke is harboring <50% stenosis. The purpose of this study was to compare the characteristics of plaque morphology and compositions between symptomatic and asymptomatic sides in patients with bilateral mild (30%–50%) carotid stenosis using multicontrast MR vessel wall imaging. We present the MR images on a 1.5T scanner with symptomatic and asymptomatic plaque causing 30% to 50% atherosclerotic narrowing.MethodsThis was an observational single-center study, we enrolled 80 patients with bilateral carotid stenosis (30%–50%) who had ischemic event within last 7 days and also harboring asymptomatic plaque on the other side. Patients were evaluated for vulnerable plaque features using MR plaque imaging is done with time of flight, T1 T2, T1 Fat sat, and T2 Fat sat sequences in axial plan. The study were planned from 2019 March to 2022 February for a total duration of 3 years. The institutional ethics committee of Pacific Medical University and Hospital board approved the use of human subjects for this study, Informed, written consent was obtained.Availability of Data and MaterialsAll data available upon reasonable request to the corresponding author.ResultsClinical and Imaging CharacteristicsA total of 80 patients were included in the study. The mean age of study participants was 57.8 years of which 52 (65%) was male. Median time of symptom onset to performing of magnetic resonance imaging was 2.3 days.In 53 (66%) patients, intraplaque hemorrhage was present in the ipsilateral carotid artery while 5 (6.2%) had it on the asymptomatic side. Fibrous cap ulceration was seen in 61 (76%) of symptomatic plaques and in 2 of the asymptomatic plaques. Lipid-rich necrotic core was present in large number of symptomatic (59%) and asymptomatic plaques (39%). However, mural thrombus was present in few symptomatic plaques only (4%; Table S1).DiscussionIn this study, we used magnetic resonance imaging plaque imaging to assess the morphological aspects of 80 consecutive patients with ischemic stroke who had mild stenosis (<50%) carotid atherosclerotic plaques. The prevalence of morphological features of high-risk atherosclerotic plaques on magnetic resonance imaging was found to be significantly higher in the ipsilateral carotid artery than in the contra lateral artery. Intraplaque hemorrhage and fibrous cap ulceration was found to be significantly more in symptomatic plaques. Many cryptagenic or idiopathic stroke may be caused by mild or nonstenosis carotid plaque.3Advanced plaque lesions become more complicated as a result of calcification, the development of new vessels, thinning of the fibrous cap, and eventually plaque rupture. Some of the plaque may not grow much or grow outward not leading to luminal narrowing on traditional luminal imaging. The strength of the fibrous cap, which is essential for plaque stability, is determined by the activity of the numerous proinflammatory and anti-inflammatory cytokines, mediators within the plaque. This establishes the balance between collagen breakdown and production (mediated by MMPs [matrix metalloproteinases] and IFN [interferon] and TGF [transforming growth factor], respectively).4 With present medical treatment, plaque stabilization may take 6 to 12 months for stabilization.5 Whereas treatment with appropriate closed stent without balloon angioplasty in most cases may act like dressing on wound or as scaffold leading to faster endothelization as early as 1 month with optimal medical management. This leads to prevention of clot going up in brain, artery to artery emboli or occlusion of vessel by plaque growth or rupture leading to hemodynamic stroke. We want to emphasize as blister aneurysm may rupture and lead to subarachnoid hemorrhage necessitating endovascular treatment. So randomized controlled trials should be conducted for a subgroup of symptomatic patients with vulnerable mild carotid stenosis to evaluate the safety and efficacy of stenting for immediate prevention of reoccurrence of stroke.Article InformationAcknowledgmentsThe authors thank Pacific Medical University and Hospital for providing facilities and support during the study. We sincerely thank Dr Shivoham Singh for the statistical analysis.Sources of FundingNone.Supplemental MaterialTable S1Disclosures None.FootnotesFor Sources of Funding and Disclosures, see page e295.Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.123.042874.*A. Vajpeyee, S. Tiwari, and L.B. Yadav contributed equally.Correspondence to: Atulabh Vajpeyee, MD, DM (Neurology), FINS, Department of Neurosciences, Pacific Medical College and Hospital, Pacific Medical University, Udaipur, India, 313001. Email researchudr@gmail.comReferences1. Kamel H, Navi BB, Merkler AE, Baradaran H, Díaz I, Parikh NS, Kasner SE, Gladstone DJ, Iadecola C, Gupta A. Reclassification of ischemic stroke etiological subtypes on the basis of high-risk nonstenosing carotid plaque.Stroke. 2020; 51:504–510. doi: 10.1161/STROKEAHA.119.027970LinkGoogle Scholar2. Naghavi M, Libby P, Falk E, Casscells SW, Litovsky S, Rumberger J, Badimon JJ, Stefanadis C, Moreno P, Pasterkamp G, et al. From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part I.Circulation. 2003; 108:1664–1672. doi: 10.1161/01.CIR.0000087480.94275.97LinkGoogle Scholar3. Rafailidis V, Charitanti A, Tegos T, Destanis E, Chryssogonidis I. Contrast-enhanced ultrasound of the carotid system: a review of the current literature.J Ultrasound. 2017; 20:97–109. doi: 10.1007/s40477-017-0239-4CrossrefGoogle Scholar4. Kautz L, Gabayan V, Wang X. Ross R: Atherosclerosis–an inflammatory disease.Cell Rep. 2013; 5(1).Google Scholar5. Konishi T, Funayama N, Yamamoto T, Hotta D, Nomura R, Nakagaki Y, Murahashi T, Kamiyama K, Yoshimoto T, Aoki T, et al. Stabilization of symptomatic carotid atherosclerotic plaques by statins: a clinico-pathological analysis.Heart Vessels. 2018; 33:1311–1324. doi: 10.1007/s00380-018-1193-6CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails July 2023Vol 54, Issue 7 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.123.042874PMID: 37264912 Originally publishedJune 2, 2023 Keywordscarotid arteriesconsentfibrous caphemorrhagemorphologyPDF download Advertisement SubjectsPhysiologyVascular Biology